Frequent use of the ER fell after the Affordable Care Act

June 12, 2018, University of California, San Francisco

The odds of being a frequent user of California's emergency departments dropped in the two years following the implementation of major provisions of the Affordable Care Act (ACA) in January 2014, according to a new study led by UC San Francisco.

In a -records study of nearly 14 million who visited a California emergency department (ED) at least once from 2012 to 2015—involving 24.5 million visits—the researchers found that the odds of being a frequent ED user declined for patients on Medicaid and the uninsured after the ACA implementation.

Overall, 6.6 million patients visited a California emergency department in the two years prior to the ACA and 7.1 million visited an ED in the two years following it. In 2012-2013, nearly 7.9 percent of those, or 522,576 patients, were frequent visitors, commonly defined as those who visit at least four times per year. After Medicaid and other coverage was expanded, those numbers rose to 8.5 percent, or 604,376 patients, in 2014-2015. Frequent users were responsible for 30.7 percent of all visits before the legislation and 31.6 percent after coverage was expanded.

This increase, however, does not account for the fact that many more people were covered by Medicaid over this time period. When the researchers controlled for the increase in Medicaid coverage and other insurance changes, they found that Medicaid and uninsured patients had 0.88 and 0.69 times the odds of being a frequent ED user, respectively, after the ACA implementation (2014-2015), compared to the pre-ACA period (2012-2013). Privately insured patients experienced little change in the frequency of their visits.

The finding suggests that the nation's largest expansion of health insurance in more than 50 years may have led to improved access to health care services, reducing the need to use emergency departments as a primary source of care, particularly among people served by public insurance programs.

"Our findings do not necessarily suggest that the ACA caused a decrease in frequent emergency department use among Medicaid and uninsured patients, but rather provides evidence that expanded Medicaid coverage might have allowed these patients to access services for serious health conditions outside of the ED," said senior author Renee Hsia, MD, MSc, a UCSF professor of emergency medicine and health policy and a core faculty member in the UCSF Philip R. Lee Institute for Health Policy Studies.

"Efforts to address frequent ED use should take into account Medicaid managed care plans and coordinated mechanisms that provide physical and behavioral health resources across networks," Hsia said.

Frequent use of the often serves as a marker for poor access to non-emergency medical care. Uninsured frequent ED use also is a significant driver in health care costs.

Before the ACA, nearly 27 percent of California's total ED patients were uninsured and frequently had the cost of their care written off by hospitals as charity care. After coverage was expanded, that number halved to 13.2 percent. Among frequent users, represented 29 percent of the total before the ACA and only 8.3 percent after, as Medicaid coverage of the frequent-user population expanded from 44.6 percent to 67.6 percent.

The study is published in Health Affairs.

Most studies of frequent ED use were conducted before 2014, when several major provisions of the ACA were implemented. Under the legislation, some 20 million adults gained health insurance coverage, primarily through expansion of Medicaid eligibility, as well as new insurance marketplaces and subsidies.

In 2017, there were 29.3 million people nationally without health insurance, down from 48.6 million in 2010, according to the Centers for Disease Control and Prevention.

The new study controlled for factors such as health status, primary insurance coverage sources and counties of residence. In addition to , other patient characteristics—including race or ethnicity and health condition—were significantly associated with frequent ED use during the study period, the researchers found. Diagnoses of a mental health condition or substance use disorder were the largest predictors of frequent ED use, with mentally ill patients having at least twice the odds. Non-Hispanic blacks also had 1.27 times the odds than non-Hispanic whites to be a frequent ED user.

Explore further: Medicaid expansion ups access to rehab in young adults with injury

More information: Shannon McConville et al. Frequent Emergency Department Users: A Statewide Comparison Before And After Affordable Care Act Implementation, Health Affairs (2018). DOI: 10.1377/hlthaff.2017.0784

Related Stories

Medicaid expansion ups access to rehab in young adults with injury

June 9, 2018
(HealthDay)—For young adults hospitalized for injury, the first year of implementation of Medicaid expansion under the Affordable Care Act correlated with significant increases in Medicaid coverage, reductions in lack of ...

Affordable Care Act expands health coverage to more patients, although differences remain

September 12, 2017
Expansion of Medicaid coverage under the Affordable Care Act has contributed to sizeable decreases in medical visits in which people were uninsured. This is true across all racial and ethnic groups, although disparities remain.

Medicaid expansion states saw ER visits go up, uninsured ER visits go down

June 19, 2017
States that expanded Medicaid coverage under the Affordable Care Act (the ACA) saw 2.5 emergency department visits more per 1,000 people after 2014, while the share of emergency department visits by the uninsured decreased ...

Does the affordable care act impact patient visits in the emergency department?

July 24, 2017
As the debate surrounding the Affordable Care Act (ACA) looms in the U.S. Congress, Johns Hopkins researchers are weighing in on one aspect of the law. In 2014, as part of the ACA, Maryland was one of the states that expanded ...

Study finds uninsured don't use emergency rooms more than other patients

December 12, 2017
One of the most common arguments for expanding publicly subsidized health coverage is that the uninsured overuse and overburden emergency departments. This argument persists despite evidence that, when the uninsured gain ...

Study finds Medicaid expansion did not increase emergency department use

August 9, 2016
George Washington University (GW) researchers published a Health Affairs study finding that the expansion of Medicaid insurance coverage in the Patient Protection and Affordable Care Act (ACA) did not increase hospital emergency ...

Recommended for you

Graphic warning labels linked to reduced sugary drink purchases

June 18, 2018
Warning labels that include photos linking sugary drink consumption with obesity, type 2 diabetes, and tooth decay, may reduce purchases of the drinks, according to a new study by researchers from Harvard T.H. Chan School ...

Study unmasks scale of patient doctor divide

June 13, 2018
A study has estimated that around three million Britons—or 7.6 % of the country—believe they have experienced a harmful or potentially harmful but preventable problem in primary healthcare.

Lentils significantly reduce blood glucose levels, study reveals

June 13, 2018
Replacing potatoes or rice with pulses can lower your blood glucose levels by more than 20 per cent, according to a first-ever University of Guelph study.

Researcher studies the impact religion has on sleep quality

June 13, 2018
Can a person's religious practices impact their sleep quality? That's the focus of a new study by Christopher Ellison in The University of Texas at San Antonio (UTSA) Department of Sociology and his collaborators.

Mediterranean-style eating with lean, unprocessed red meat improves heart disease risk

June 13, 2018
Adopting a Mediterranean-style eating pattern improves heart health, with or without reducing red meat intake, if the red meat consumed is lean and unprocessed, according to a Purdue University nutrition study.

Sleeping too much or not enough may have bad effects on health

June 12, 2018
Fewer than six and more than ten hours of sleep per day are associated with metabolic syndrome and its individual components, according to a study published in the open access journal BMC Public Health that involved 133,608 ...


Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.